Discharge and Transferfrom NUH Policy

Reference / CL/CGP/036
Approving Body / Trust Board
Date Approved / 28 May 2015
Implementation Date / 28 May 2015
Version / 5
Supersedes / Version 4(February 2012)
Consultation / Clinical Leads
Medical Director
NUH Discharge project leads
Matrons
Infection Prevention and Control Team
Directors’ Group
Integrated Discharge Team
Transport Manager
Safeguarding lead
Date of Completion of Equality Impact Assessment / May 2015
Date of Completion of We Are Here Assessment / May 2015
Date of Environment Impact Assessment (if applicable) / Not applicable
Target Audience / All staff involved in Discharge and Transfer Planning for patients.
Supporting Documents/References / Refer to References
Review Date / March 2017
Lead Executive / Chief Nurse
Author/Lead Manager / Fiona Branch
Better for You Discharge Team
Further Guidance/Information / Integrated Discharge Team

CONTENTS

Paragraph

/ Title / Page
1. / Introduction / 4
2. / Background / 4
3. / Policy Scope / 5
4. / Policy Statement / 5
5. / Principles / 6
6. / Enacting the Principles / 8
7. / Responsibilities / 9
8. / Nurse facilitated discharge / 12
9. / Common arrangements for discharge and transfer / 13
9.1. / Transportation (including bariatric and DNACPR patients) / 13
9.2 / Dressings / care products and medicines to take out / 13
9.3. / Equipment to take out / 14
9.4. / Medical Certificates / 15
9.5. / Medical Device Removal / 15
9.6. / Specialist Nurse Involvement / 15
9.7 / Outpatient Appointments / 15
9.8 / NHS continuing care (CHC) and NHS funded Nursing Care / 16
9.9 / Fast Track Pathway for Continuing Healthcare / 17
9.10 / Mental Capacity and Independent Mental Capacity Advocates / 17
9.11. / Patient Advocacy and Voluntary Arrangements / 18
9.12 / Carers / 18
9.13 / Delayed transfer of care (‘delayed discharge’) / 19
10 / Specific arrangements for Discharge / 19
10.1 /
Documents to accompany the patienton discharge
/ 20
10.2. / Patients taking their own discharge against medical advice / 20
10.3. / Discharge/transfer to a care Home (New) or up-rating from Residential to Nursing Home / 21
10.4 / Out of Hours Discharge / 23
10.5. / Out of Hours Self Discharge / 24
10.6 / Patients refusing to be discharged / 24
10.7. / Discharge of Day Case Patients / 25
108. / Discharge of Emergency Department Patients - including homeless, end of life, asylum, learning difficulties / 2530
11.1 / Transfers to specific Locations / 30

Paragraph

/ Title / Page
12. / Internal NUH Patient transfers / 32
13. / Training/Awareness / 32
14. / Implementation and Monitoring / 33
15. / Equality and Diversity Statement / 34
16. / Equality Impact Assessment Statement / 34
17. / Here for You / 35
18. / References and related policies and procedures / 35
Appendix 1 / Glossary of Terms / 36
Appendix 2 / Equality Impact Assessment / 37
Appendix 3 / Environmental Assessment / 39
Appendix 4 / We are Here For You / 41
Appendix 4 / Policy Implementation Plan / 42
Appendix 5 / Certification of Employee Awareness. / 43

1.Introduction

1.1At NUH we believe that patients should be looked after and treated in a setting which is appropriate to their needs and, as far as practicable, meets their preferences.

1.2This policy describes best practice guidelines for all NUH staff who aretransferring a patient from NUH care (discharge to home or transfer to another care provider). There is a separate Policy for internal NUH transfers.

1.3Patients and their carers should receive person-centred transfers of care which respectthem as individuals and recognise both their individual needs and personal preferences. This requires clinicians and managersto:

  • ensure that patients and their carer(s) are listened to and engaged

in care-planning decisions

  • enable patients to make informed choices, and be involved in all

decisions about their needs and support

  • involve and support carers whenever necessary
  • respect patients dignity and privacy and recognise individual

differences and specific needs including those arising from cultural

and religiousdifferences

  • provide co-ordinated and integrated responses to patient needs
  • needs and to enquiries about care

Each transfer (discharge) needs to be safe, effective and caring. It should also be efficient to ensure that each patient receives the right care, in the right place, at the right time.

This policy complies with relevant Department of Health policy and guidance, National Health Service Litigation Authority (NHSLA) standards, local standards and local joint agreements, for all in-patients.

2Background

2.1NHS organisations and Local Authorities (Social Service functions) are required to comply with the regulations and obligations created by the Community Care (Delayed Discharges etc) Act 2003.The Act places duties on NHS bodies and Local Authorities in England to communicate with each other and with patients and carersabout the discharge of a patient from hospital. The NHS is required to notify the relevant Local Authority (council) of apatient’s likely need for community care services, and of his/her proposed discharge date.

2.2Continuing Health Care 2009

NHS Continuing Healthcare (CHC) describes an adults (aged 18 or over) entitlement to care that meets physical or mental health needs that (1) have arisen as a result of disability, accident or illnessand (2) meet local Eligibility Criteria. Broadly, to meet the criteria for NHS continuing care an individual’s needs must be intense, complex, unpredictable, unstable and deteriorating. If a multi-disciplinary assessment suggests that a patient may meet these criteria, referral is made to a team of assessors. They will carry out their assessment of need against the eligibility criteria.

The NHS is responsible for arranging and funding NHS CHC services for eligible patients who are in a hospital, a care home, or their own home.

3Policy Scope

3.1This Policy applies to all patientsbeing discharged from inpatient care in NUH, regardless of age or diagnosis. This Policy should be read in conjunction with the Trust’sSafeguarding for Adults and Children (including those in need of protection) Policies.

3.2This Policy applies to alltransfers/dischargesfrom hospital,including out-of-hours discharge, external transfer, and end-of-life care discharge.

3.3Carers are people who care, unpaid, for friends or family members who are ill, frail or disabled (NUH Carers Policy May 2014). Under the care Act 2014 a carer is someone who helps another person, usually a relative or friend, in their day-to-day life. This is not the same as someone who provides care professionally, or through a voluntary organisation.

4Policy Statement

4.1 The Trust is committed to ensuring that each patient is safely and effectively discharged or transferred.The Trust will, so far as is reasonably practicable, seek to ensure that;

  • All patients experience well-organised, safe and timely assessment and discharge from hospital (unnecessary delays in transfer of care or discharge will be minimized).
  • Each patient, and where appropriate their carer and family, is prepared, physically and psychologically, for transfer home or to an agreed alternative environment.
  • There is effective and timely consultation with patients and their families and/or carers in planning and managing the transfer/discharge process.
  • Patients and their families and/or carers are supported and assisted throughout the process.
  • There is effective communication between hospital and community multi-disciplinary/multi-agency teams.Sharing of patient information must adhere to the principles of confidentiality and consent.
  • Appropriate documentation accompanies the patient on

transfer/discharge.

4.2Patients do not have the right to choose a non-available transfer location, to insist on the provision of informal care, or to remain in hospital when there is no clinical need.

4.3 Patients with mental capacity for the decision have the right to make what others regard as unwise or ‘risky’ decisions about transfer location.

5Principles

5.1Discussion about transfer should start early (if possible before admission) to anticipate problems, plan for transfer and agree an expected transfer date and location.

5.2A person-centred approach which treats individuals with dignity, respect and fairness, and meets their diverse and unique needs should be maintained.

5.3The patient (or their carer if appropriate) should be at the centre of any decision-making and should be consulted(including about their choices) at all stages of the process.

5.4 Patients should be provided with good informationto enable them to make care-planning choices.

5.4Transferring / discharging staff should maintain an awareness of an individual’s gender, religion, sexual orientation, race, ethnicity, disability, age and culture throughout the discharge process, and consider implications for discharge that may arise due to these characteristic.

5.5Where patients agree, relatives and carers should be included in assessment, planning and implementation transfer/discharge.

5.6Where patients do not wish other individuals or agencies to become involved, NUH staff (and staff of other agencies working with NUH patients) should respect those wishes, except where there are compelling grounds for believing that the patient lacks the necessary competence/ capacity to give (or withhold) consent for the proposed action (e.g. inter-agency referral, discussion or intervention). [See Consent to Examination or Treatment Policy]. Competent patients have freedom to choose their discharge destination and care [see Mental Capacity Act Policy and the Consent to Examination or Treatment Policy].

5.7Competent patients have the right to choose their discharge destination and care [see Mental Capacity Act Policy and the Consent to Examination or Treatment Policy]. Relatives/carers do not have the right to overrule a competent patient’s choice. ]

5.8The rights of patients who do not have capacity to make decisions about transfers must be protected, as enshrined in the Mental Capacity Act 2005.

5.9There should be effective communication between practitioners, patients and carers through planning and enacting the transfer.

5.10Planning for complex transfers should be multidisciplinary, based on collaborative multi-professional and multi-agency working, one feature of which is agreement about who is responsible for specific actions and decisions on the process and timing of transfers.

5.11Social services should be involved where appropriate, and agreed standards for timely assessment and notification(s) by NUH should be met.

5.12Most carers have a legal right to an assessment of their own needs (by the relevant local authority) to support them in their caring role (separate to the assessment of the patient’s needs).

5.13Eligibility for NHS continuing health care should be described, and considered where appropriate.

6. Enacting the Principles (Actions for NUH staff)

6.1Transfer / discharge is an active process. Safe transfer / discharge requires that hazards of the process to patients are identified and controlled (risk assessment and mitigation). This is particularly important for the discharge of patients who have complex needs. The current NUH Transfer of Care/Discharge Pathway is attached [Appendix 1].

6.2Transfer/discharge plans and discussions of each patient should be recorded clearly in the medical and/or nursing notes. These plans should be reviewed daily.

6.3Start planning for transfer at or before admission.

6.4Identify whether the patient has simple or complex transfer needs, and involve the patient and carer in that decision.

6.5Develop a clinical management plan for every patient within 24 hours of admission, and expected date of transfer within 48 hours.

6.6Identify to patients and carers/relatives a Predicted Date of Medically Safe for Transfer (PDMST) as soon as possible after admission.

6.7Coordinate the transfer of care process through effective leadership and handover of responsibilities at ward level.

6.8Review the clinical management plan with the patient each day, take any necessary action, and update progress towards the transfer date.

6.9Ensure timely referrals for necessary / appropriate specialist advice or services and be clear about the impact of the referral on the transfer/discharge process. This includes ‘withdrawing’ notifications when circumstances have changed.

6.10Involve the patient and carer(s) so they can make informed decisions and choices that deliver a personalised care pathway and maximise their independence.

6.11Consult with the patient, and their carer, prior to a referral to a community service for assessment. .

6.12Plan transfers to take place on each of the seven days.

6.13Plan transfers to be as early in the day as practicable.

6.14Use a checklist 24-48 hours before transfer; this should include a plan for post-transfer clinical care.

6.15Make decisions about transfers each day (7/7).

6.16Ensure effective and timely communication/handover with all relevant agencies.

6.17Ensure that appropriate documentation is available for each patient at the time of their transfer/discharge.

6.18Ensure that completion of a patient’s discharge documentation (including prescription, ‘TTO’ (Tablets to Take Out) does not introduce unnecessary delays in the patient’s transfer/discharge.

6.19NUH will ensure that dispensing a patient’s discharge medications does not introduce unnecessary delays in the patient’s transfer/discharge.

7Key Responsibilities

7.1The Chief Nursehas overall responsibility for ensuring that there is an appropriate NUH policy, and that effective systems and processes in placeto underpin the safe discharge orexternal transfer of patients.

7.2The Medical Director is responsible for ensuring that effective systems and processes are in place to allow Medical Staff to transfer/ discharge patients.

7.3Clinical Directorswill ensure that this Policy is implemented and monitored, and will investigate non-compliance and implement actions to maintain or improve compliance.

7.4The Responsible Consultant(Midwife for women admitted for Midwifery-Led care) is accountable for all medical aspects of the patient’s pathway (including the discharge or transfer of care). S/he may delegate this responsibility to competent medical staff or to nursing/ midwifery staffwho have been assessed as competent to carry out Nurse / Midwife Facilitated Discharge (NFD).

7.5Heads of Service are responsible for ensuring that there is a process for daily review by a senior clinician to identify those patients who are ready for transfer/discharge (and that this is documented), and compliance with that process.

7.6The Consultant (or senior decision-maker to whom they have delegated) undertaking the daily review (7.5) is responsible for identifying (or reviewing) a ‘Predicted Date of Medically Safe for Transfer (PDMST) on each patient during the daily review, and that this is recorded on Medway PAS.

7.7The Responsible Consultant is responsible for ensuring that:

7.7.1Patients who are potentially ready for discharge should be reviewed as early in the day as is consistent with clinical priorities (i.e. at the beginning of ward-rounds whenever practicable).

7.7.2Patients approaching the last days or weeks of life are considered for the fast-track discharge process (and where appropriate the fast track checklist should be completed).

7.7.3Referrals to other specialist teams or services necessary to formulate comprehensive diagnostic, treatment (including rehabilitation) and transfer discharge plans are made without unnecessary delay.

7.7.4Prescriptions for discharge are written at soon as is safe and practicable.Where there is less than 24 hours notice of transfer/discharge, the prescription should be completed as soon as practicable after the decision to transfer/discharge. For eTTOs this will mean that it is at a Stage 2 by 15.00 on the day prior to transfer.

7.7.5Appropriate and adequate written information (TTO/ eTTO; electronic Tablets to Take Out) is available for dispatch to the GP at the time of discharge.

7.7.6Where the patient is discharged to a residential or nursing home a copy of the discharge summary is sent to the ‘Medical Officer’ at the home’s address.

7.7.7For patients not registered with a GP, advice is taken from the Supported Transfer of Care Team or CCG.

7.7.8For children and young people the Health Visitor is informed, and for babies the Community Midwife.

7.8The Site Matron will:

  • Monitor bed pressures on an hour-by-hour basis, and escalate actions and contingencies (including those around discharge) as required, and according to NUH procedures (including informing Silver On-call )
  • Attend escalation meetings in response to bed pressures

7.9Matronswill:

  • Ensure implementation of systems to support this policy in their area of responsibility (including for outlying patients), which they will keep under regular review
  • Take appropriate action when delays in patient pathways occur
  • Attend regular Trust-wide discharge meetings, or send a deputy

7.10Ward Sisters/Charge Nurses/Team leaderswill

  • Ensure that all staff are aware of and comply with the NUH Transfer of Care/Discharge Pathway, and thispolicy and monitor standards and work with managers and staff to ensure compliance.
  • Ensure that an effective discharge planning process operates in the ward.
  • Ensure any delayed discharges are escalated appropriately, and in a timely way.
  • Attend regular bed meetings or send a deputy (who may be the discharge coordinator). At the meeting they will identify the number of predicted discharges and any issues which are impacting on effective discharge from their ward /clinical area
  • Ensure that the bed management system and other hospital IT systems are updated in as real time as possible

7.11Registered Nurses, Midwives, Practitioners and Allied Healthprofessionals will

  • Ensure that they can demonstrate the appropriate skills and knowledgeneeded to enable them to provide the necessary standard of care in the assessment of a patient requiring discharge and determine the appropriate level of risk and discharge care requirements.
  • Ensure that patients, carers and members of the MDT are fully involved at all stages of the admission/discharge process

7.12Discharge Coordinatorswill

  • Ensure that ward discharge processes follow the NUH Transfer of Care Pathway.
  • Ensure that patients, carers and members of the MDT are fully involved at all stages of the admission/discharge process
  • Help ward staff to improve discharge by optimising the use of IT and information, and updating hospital systems in as real time as possible.
  • Attend regular Trust-wide discharge meetings (at request of ward manager). At the meeting identify the number of predicted discharge Inform the ward manager of any issues that are impacting on effective discharge from their ward

7.13The Supported Transfer of Care Team (STOC) will:

  • Support staff in discharge or transfer of adult patients
  • Advise and help train staff about the discharge planning process
  • Advise on complex discharge and continuing health care needs
  • Assess patients’ for suitability for short/long term rehabilitation
  • Attend regular Trust-wide discharge meetings
  • Inform their line manager of any issues that are impacting on effective discharge processes
  • Record data relating to the STOC transfer process

7.12Pharmacists will:

  • Ensure that Tablets to Take Out (TTOs) are checked and dispensed in a timely manner
  • Pre-transcribe TTOs into the e TTO system, whenever possible.
  • Ensure that the final check box on the discharge prescription is signed off indicating that the checking of medications is complete.
  • Advise patients and staff relating to discharge medication
  • Attend regular Trust-wide discharge meetings
  • Inform their line manager of any issues that are impacting on effective discharge processes

7.13The Hospital Palliative Care Team will provide advice and support for the transfer of complex end of life and palliative care patients.